Medicare agrees to cover bariatric surgery

Washington -- Bariatric surgeons are declaring victory in their quest to convince Medicare to cover weight-loss procedures for all morbidly obese beneficiaries for whom it's medically necessary.

In a national coverage determination issued last month, the Centers for Medicare & Medicaid Services agreed to cover three types of bariatric surgery for seniors and disabled people with body mass indices of 35 or greater as long as they have at least one obesity-related condition and have unsuccessfully tried to lose weight without surgery. A proposed rule that CMS released last November would have covered only two types of surgery, and only for beneficiaries younger than 65.

"Bariatric surgery is not the first option for obesity treatment, but when performed by expert surgeons it is an important option for some of our beneficiaries," said CMS Administrator Mark McClellan, MD, PhD. The agency changed its mind about covering seniors after reviewing clinical evidence suggesting that mortality rates from the procedures were not substantially higher for this population.

Surgeons who regularly do the procedures hailed the move as a win for morbidly obese patients and the doctors who treat them. Government help in paying for the surgeries, which can run tens of thousands of dollars, will go a long way in alleviating health effects of obesity's comorbidities, such as diabetes and heart disease, said Harvey Sugerman, MD, the American Society for Bariatric Surgery's immediate past president. "The cost savings would be significant for Medicare, and the health implications would be enormous," he said.

Although in the past Medicare has allowed coverage of gastric bypass surgery for beneficiaries with an obesity-related condition, such decisions were made by individual carriers at the local level. With a national coverage mandate, doctors and patients no longer will face a patchwork of coverage.

Limits on surgery facilities

The coverage announcement capped a nearly year-long review process that started last May when the bariatric surgery society officially requested the national coverage determination. The fight to get Medicare to treat obesity itself more as a disease has raged for far longer. But observers shouldn't expect the number of surgeries paid for by Medicare to skyrocket now that the group has achieved one of its primary goals.

In a major change from its proposed determination, CMS decided to restrict the surgeries to facilities that have been deemed either centers of excellence by the American Society for Bariatric Surgery or level 1 bariatric surgery centers by the American College of Surgeons. This will indirectly limit the pool of doctors who will be able to perform the procedures on Medicare patients.

To qualify, a facility must do a certain number of surgeries per year and have the full staff complement required to treat the entire set of complex conditions caused by morbid obesity. CMS decided to impose the certification requirement, a move supported by the bariatric surgery society, because the quality of the surgery varied across the nation, said Steve Phurrough, MD, director of the agency's Coverage and Analysis Group.

"Good bariatric surgeons were concerned that their reputations were being challenged by the bad surgeons," he said. "So they wanted to make sure that only good surgeons were going to be part of the process of doing this."

The federal ruling means that certain procedures that Medicare covered before on a local basis are now prohibited. That change, along with the facility limitation, likely will temper the growth of Medicare-approved bariatric surgeries. The program now pays for roughly 3,300 surgeries a year, about 300 of which are done on seniors, and officials don't expect a huge increase in these numbers.

Some of the more than 500 comments CMS received on its proposed rule came from physicians who said the procedures could be a drastic and potentially dangerous alternative to nonsurgical obesity interventions for some or all patients.

Some physician groups, including the American College of Surgeons, expressed concern about encouraging the surgery for those age 65 and older. Commentators said this could open seniors up to greater risks of death than they face from their obesity conditions. Others said the procedures are never appropriate for patients.

Neil Hutcher, MD, American Society for Bariatric Surgery president, countered that physicians who oppose the surgery for all patients regardless of age are simply prejudiced against morbidly obese people. "If these patients didn't eat, they wouldn't store all this energy, but it's far more complex than that," he said. "If people didn't eat, they wouldn't have heart disease. If people didn't smoke, they wouldn't have lung cancer. If people didn't ride motorcycles, they wouldn't have head trauma. But has anybody ever said, 'Let's not treat them because they misbehaved'? Why is morbid obesity the only behavior that's forbidden?"

Coverage decisions such as this one also pose Medicare payment concerns. Groups including the American Medical Association have repeatedly called on CMS to factor the expected increase in utilization that accompanies any major coverage expansion into the Medicare reimbursement formula. Under the current payment system, increased utilization can cause physician spending to exceed predetermined annual targets, resulting in subsequent deep cuts to doctor pay.

"When the impact of regulatory changes ... is not properly taken into account, physicians are forced to finance the cost of new benefits and other program changes through cuts in their payments," AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, wrote last September in a letter to CMS regarding the 2006 Medicare physician payment rule. "Not only is this precluded by the law, it is extremely inequitable and ultimately adversely impacts beneficiary access to important services."